TVC15

Sorry but I don't work in heme. I have only worked as a Reference Lab Blood Banker but was trained at a very top notch cancer center as a generalist. We received a very thorough and solid training in hematology. This practice was never done in that lab and when I called to ask the seasoned Hematologists after seeing a CLS doing this they were also surprised at this practice. I have found zero literature other than one very old paper that recognizes or supports this practice. I now work as a CLIA consultant. My question is how do you know that some of the WBC organelle fragments are not being stained and counted as PLT's. You say that after vortexing you see no significant difference then why do it to begin with? Also how do you know if a first time patient in the ER has no major issues?

Hi I am not only concerned about the red cells lysing. But actually red cells that have reached their life span will lyse easily. And on top of that certain cancer, sickle cell and anemic patients do have fragile RBC's. Also what about WBC fragmentation? How do you know that you are counting true platelets and not RBC or WBC fragments after vortexing? I am all open to learning new things but logically this just does not sound like a good practice.

http://www.msnbc.msn.com/id/49344676

I emailed the company to inquire if this product was available in the US and this was their response: Thank you for your interestin our ThromboExact S-Monovette. Unfortunately, we are not selling theThromboExact in the USA and have not yet sought regulatory510(k) clearance. If you have any furtherquestions please do not hesitate to contact us.

Thanks Alan that is very interesting! I wonder if that product will head over to the US anytime soon...or is it possibly already here? Thanks for posting it!

I GOOGLED it and found this http://www.medizinische-diagnostik-dreieich.de/transfusion/BedsideKartenEN.aspx

I never heard of this practice until I moved to CA. One hospital in San Francisco uses it. They send a CLS to the bedside to perform a finger stick. They also charge the patient for the bedside check. Once the bedside is performed then it is never performed again. Only one bedside per patient history.

There are other ways to make sure you have the correct blood type on a patient. The places that use electronic cross matching...two separate blood types are required. The 2 blood bank specimens must come from separate draws at different times by different phlebotomists. The testing in the Blood Bank for the first specimen must be tested by one CLS and the second specimen must be tested by a different technologist. Once this record is established and the blood types match no more testing of the patient’s blood type is required. This does not have to be performed on the same day. If a patient comes in for presugery labs then that can be the first BB spec. The day of surgery the second BB specimen must be drawn and tested prior to givng blood to the patient. Hospitals can also employ the BB armband number or scan. Nurses must have the patient’s armband scan which also goes on the patients chart, BB specimen and unit tag when cross matched. The nurse can only transfuse once all scans agree. The nurses goes to the bedside with a scanner to make sure all electronic data matches before transfusing.

Hi Alan, How do you perform the methodology? What commercial product do you use? Thanks

No worries James, I understand how people react when challenged on something they firmly believe in. I have solid experience as a CLS for many years. I was well trained as a generalist at M.D. Anderson. I did all of my rotations in the Texas Medical Center at some of the best hospitals in the nation. The one thing about training in the TMC is the entire complex is a teaching and research complex with cutting edge technology and practices. The M.D. Anderson CLS's are very lucky to get exposure to this. I find that us modern day trained CLS's see and do things much differently than the longer careered CLS's. For example old blood bankers do some of the strangest things I have ever seen. Some of them are still stuck in the 70's era. Technology and practices constantly evolve...but unfortunately many CLS's don't evolve with them. I do think outside the box that is why I question things. I have never been asheep that goes along with what people tell me. I research and find out for myself. Peace

Hey guys I looked up the doctor who wrote the CAP article. I emailed him and this is what he had to say: Hi Dr. Kroft, I would like to ask you about your answer on the CAP Q&A vortexing CBC specimen to get rid of platelet clumping. I read what you wrote on that site and find it highly shocking. I studied at M.D. Anderson and the hematology department could not believe that anyone would do this to a CBC specimen to resolve the issue. I think it is a terrible practice that could lead to a falsely elevated platelet count. Vortexing will certainly break up some RBC’s and other cells and thus could be counted as platelets when run through the analyzer a second time. Do you still think this is a good practice? Thank you, His response: I have never actually employed this procedure. The information regarding vortexing was based on a single paper in the literature that studied its effectiveness in resolving platelet clumps. I don't have the paper at hand, and I don't recall whether they evaluated the post-vortex sample for red cell fragmentation. The reference should be provided in the CAP Today column, and I would encourage you to to dig it up and see what they did. Your point is certainly a reasonable consideration, although I have no specific knowledge that vortexing fragments red cells. It would be worth testing the hypothesis, and I would be interested in the results of such an experiment. Regards, SHK

I think you need to be more astute when reading. The study was conducted in 1997. http://labmed.ascpjournals.org/content/32/7/361.full.pdf See reference #10 from this paper. Interesting that you think all docs are spot on. I was unfortunately misdiagnosed in 2009 by a team of doctors from UT Southwestern in Dallas...imagine that. A team of UT Southwest doctors misdiagnosed that I had osteomylitis in my dominant wrist and hand bones. This misdiagnosis resulted in permanent damage to my dominant hand bones and wrist bones. A team of 12 doctors from UT Southwestern and not one of them got it right!

f You bet I read it and from what I read it does not have much evidence or support to make this into a gold standard. Secondly this was not written or produced by CAP It was answered by a doctor on a CAP Q&A section. Did you take note on how old the references are? Did you also miss the part where he said they did an informal study...that's right informal study. So there is only one published paper out there from ages ago commented on by a doctor who did his own informal study and found only 50% of the time it worked. Yep sounds like this really ought to be a high hematology standard. I would rather have a patient redrawn in order to obtain a proper platelet count v.s mickey moussing around with a practice that only gives a 50% shot at it and is not commonly used. I challenge you to show me a standard that supports this practice. You won't find one out there since it is not a good practice...if it were then it would certainly be a standard. This is why he states "The most commonly employed solution to this problem is to redraw the specimen into a different anticoagulant, usually either sodium citrate or acid citrate dextrose; this resolves the problem in most cases". BTW you are dead wrong about M.D. Anderson. That is one of the top notch research instutions on this planet. I obtained my CLS degree from there and we were trained by physicians as well as very experienced MT's. I am thankful to have gained my experience from the top Medical Center and Cancer Center in the world. They did not get to that level by following poor practices.

LOL! I would take M.D. Anderson's long history of outstanding experience and accept it more than a M.T. who thinks that vortexing is the correct thing to do. Did you question who taught you to do this or just blindly accept it since everyone else in your lab is doing it? You never raise standards by being just a sheep that follows and never questions. Additionally what sort of technical judgement are you practicing when vortexing no doubt breakes up RBC's and generatates cellular fragments...then you run this through the analyzer again and assume that the platelet count is actually only platelets that were counted vs. the fragments generated by vortexing? Please show a link to the standards that support such a practice. BTW M.D. Anderson did not say that they despsied it...they just could not make one ounce of logic as to why anyone would do such a thing.

Hi Mabel, This was the only article I could find when I googled http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=cap_today%2Fq_and_a%2Fqa_0401.html&_state=maximized&_pageLabel=cntvwr This seems to be a very outdated practice. M.D. Anderson Cancer Center is the most outstanding Cancer Center on the planet...if they were shocked as much as I was and others I have mentioned it to...then it can't be all that common today. Logically it just does not make sense to me especially when there are other means to resolving this. You guys that vortex...did you ever consider that vortexing will break up RBC's and other cells and the bits that are broken off might be counted as platelets? Therefore you get a falsely elevated platelet count.

I called M.D. Anderson last night and asked the hematology crew and they were in total schock that anyone would do such a thing. It is not a good practice. Below is a part of an email from a hematology friend of mine here in CA at a large teaching facility. I 100% agree with him! Thanks everyone! You do not have to callM.D. Anderson, no one in his right frame of mind would allow such practice.Vortexing will cause significant hemolysis and will not remove clumping. You donot have to believe such statement…

Anyone out there?

Hi everyone, I am a well trained generalist but have only worked in blood bank reference labs since my training. I have just encountered a startling situation...based on my training. The CLS's where I work are trained to vortex any CBC specimen if it is suspect for platelet clumping and then re-run it on the analyzer to see if it increases the platelet count. Is it just me or do you guys think this is nuts?

Thank you Joy...I sent you a private message about the Surveyor position in CA. I was hired by a ref. lab last year to help straighten out the 37 COLA violations the lab had received. I was very impressed with how thoroughly COLA combed through that lab and found all that they did. I had never heard of COLA until I was hired as a CLIA consultant to help this lab. I would very much enjoy helping to raise the standards in CA to what they should be.

Thank you Joy...I sent you a private message about the Surveyor position in CA. I was hired by a ref. lab last year to help straighten out the 37 COLA violations the lab had received. I was very impressed with how through COLA combed thorough that lab and found all that they did. I had never heard of COLA until I was hired as a CLIA consultant to help this lab. I would very much enjoy helping to raise the standards in CA to what they should be.

Believe me guys I know what the law is and I went to school and was trained at the number one most prestigious and largest Medical Centers in the world. I have worked at very high standard blood banks before moving here. I moved to CA 2.5 years ago and have been absolutely disturbed by the practices here. CLS here don't even know that they are required to follow the manufactures package inserts or that you need to read the user guide before operating any analyzer. I have seen so much that I just HATE being a blood banker in this state. I am so close to becoming a state inspector to try and turn this state around. It is criminal what I have seen here over the years. I spoke to our Lab Director about this policy last week and let her know that it is against the law. Her response was that our Medical Director signed off of on that SOP so it all falls in her lap if anything goes wrong. I was dumbfounded but hey I'm in CA would I have expected anything other than that as a response? I mentioned it again yesterday and she tells me that she is going to tell the Medical Director that this is coming out of the SOP. IMO it should have been taken out as soon as I reported it to her. But hey I am in CA.

OK here we go! I moved here from a state with very high standards across the board in blood banking. I moved to a state with the most unbelievable noncompliance issues that I have ever witnessed in my entire career. It is like a third world country here when it comes to standards and compliance. I just discovered that our blood bank allows the blood bankers to indicate premedication for patients receiving transfusions. What the hell was my first reaction? This is completely against the law! We are not physicians nor are we in a position to tell any nurse to pre medicate a patient. The more I encounter in this state the more I just can't believe what I am encountering. Have any of you ever heard of such a thing?

Please don't tell me it is in Houston at the TMC Anyway if you cannot tolerate the non-compliance issues (which I could not) and they are not open to suggestions for change then have the FDA and CAP or JCAHO deal with them. It is very important to document everything...that should be easy as we blood bankers are documentation experts!

I worked at a very horrible Level 1 Trauma Center in Dallas that had some very questionable and noncompliant BB issues. I documented everything...found another job and turned them over to the proper regulatory agency...I hope it is not the same place but it sounds like it.

I round my circle by way of the fact that anti-D is the most immunogenic of them all and if you made anti-D you have an increased probability to make any of the other Rh antibodies who's antigen you don't possess. If you are one of the few who do not become sensitized via an O Pos transfusion then your probability to make any of the other Rh antibodies also decreases. And by the fact that anti-D is the most immunogenic of them all.